Treatment of Redness and Swelling of the Head of the Penis
For redness and swelling of the glans penis (balanitis), apply topical antifungal cream (clotrimazole 1% or miconazole 2%) 1-3 times daily for 7-14 days, as this is most commonly caused by Candida albicans, especially in uncircumcised males. 1, 2
Initial Assessment and Red Flags
Before initiating treatment, you must immediately rule out surgical emergencies:
- Suspect penile fracture if there is penile ecchymosis, swelling, a cracking/snapping sound during intercourse, and immediate detumescence—this requires urgent surgical exploration 3
- Evaluate for urethral injury if blood is present at the urethral meatus, gross hematuria, or inability to void 3
- Rule out Fournier gangrene if there is fever, severe pain, crepitus, or rapidly progressive necrosis—this requires immediate surgical debridement and broad-spectrum antibiotics 1
- Assess for ischemic priapism if the penis is completely rigid and painful—this is a medical emergency requiring intracavernous treatment 1, 3
Most Common Cause: Candidal Balanitis
Candida albicans is the most frequent cause of balanitis, with increasing incidence primarily transmitted through sexual intercourse 2:
- Apply topical antifungal agents: Clotrimazole 1% cream or miconazole 2% cream applied to the glans 1-3 times daily for 7-14 days 1, 2
- Alternative topical options include terconazole 0.4% cream for 7 days or tioconazole 6.5% ointment as a single application 1
- Consider oral fluconazole 150 mg as a single dose for more widespread or recurrent infections 1
- Treat sexual partners if the patient has recurrent infections, as male partners may develop balanitis characterized by erythematous areas on the glans with pruritus 1
When to Suspect Bacterial Infection
If there is purulent discharge, severe swelling, or systemic symptoms (fever, malaise), bacterial infection is more likely:
- For patients under 35 years: Give ceftriaxone 250 mg IM once PLUS doxycycline 100 mg orally twice daily for 10 days 1, 4
- For patients 35 years or older: Give ofloxacin 300 mg orally twice daily for 10 days OR levofloxacin 500 mg orally once daily for 10 days 1, 4
- Obtain cultures before starting antibiotics: Gram stain of any discharge and NAAT testing for N. gonorrhoeae and C. trachomatis 1, 4
- Mandatory reassessment at 3 days: If no improvement, consider abscess requiring surgical drainage, or atypical organisms 1, 4
Adjunctive Measures
Regardless of etiology:
- Improve hygiene: Gently retract foreskin (if uncircumcised) and clean with warm water daily 2, 5
- Avoid irritants: Stop using soaps, lotions, or other potential chemical irritants on the glans 2
- Abstain from sexual activity until treatment is completed and symptoms resolve 1
- Consider circumcision for recurrent balanitis, as circumcised males have 68% lower prevalence of balanitis 5
Special Considerations for Chronic or Atypical Cases
- Balanitis xerotica obliterans (lichen sclerosus) presents with white, sclerotic plaques and may cause phimosis—treat with 2.5% testosterone propionate ointment, which is superior to corticosteroids 6, 7
- Immunocompromised patients (HIV, diabetes) have higher risk of fungal infections and may require systemic antifungal therapy rather than topical treatment alone 2, 5
- Persistent cases despite appropriate antifungal treatment warrant biopsy to rule out penile cancer, especially if there is ulceration or induration 2, 5
Common Pitfalls to Avoid
- Do not delay surgical consultation if you suspect penile fracture, Fournier gangrene, or abscess formation—these require urgent intervention 1, 3
- Do not confuse non-ischemic priapism (tumescent but not rigid, painless) with ischemic priapism (completely rigid, painful)—only the latter is an emergency 1, 3
- Do not use over-the-counter antifungal preparations without confirming the diagnosis if symptoms persist beyond 2 months or worsen during treatment 1
- Do not forget to evaluate and treat sexual partners for sexually transmitted causes to prevent reinfection 1, 4